Streamlining Health IT Systems to Reduce Medical Errors

“With AHRQ funding, we have been able to develop machine learning algorithms to identify health IT-related usability and safety issues from patient safety event reports. Safety analysts are now using these algorithms to identify relevant usability and safety issues in their reporting systems so that they know where to focus improvement efforts. The outputs from these algorithms are being used by other researchers as a foundation for their work to advance usability and safety methods and improve health IT more generally.”

Raj Ratwani, Ph.D., Director of the MedStar Health National Center for Human Factors in Healthcare in Washington, D.C., investigates ways to develop health information technology (health IT) tools and processes that help clinicians keep patients safe while maximizing quality and efficiency. Conducted through multidisciplinary teams, Dr. Ratwani’s AHRQ-funded research helps frontline clinicians reduce the risk of medical errors by improving how health IT systems operate.

An Associate Professor at the Georgetown University School of Medicine in Washington, D.C., Dr. Ratwani began his AHRQ-funded work in 2013 with a grant to investigate ways to mitigate disruptions for busy emergency room physicians. Emergency room physicians are frequently interrupted, which can disrupt workflow and result in increased patient safety risks. Dr. Ratwani developed and tested simulation-based training scenarios to help emergency medicine physicians learn and practice specific cognitive strategies aimed at mitigating these disruptions.

Dr. Ratwani later shifted his focus to improving how patient safety hazards are identified in health IT systems. Improving how patient safety events are reported and analyzed in large data systems gives patient safety leaders more actionable information to rapidly identify hazards and take action to improve processes that may impact the care process.

Building on his health IT work, Dr. Ratwani received additional AHRQ funding to study health IT-related safety events and determine the critical factors necessary to ensure the safe and effective use of health IT. This included analyzing events associated with electronic health record (EHR) usability and then identifying design and implementation improvements to address those issues. EHR usability is a critical research area, as studies have shown that EHR errors, including data entry and interoperability issues, can contribute to patient harm events.

Currently, Dr. Ratwani is assessing patient safety hazards associated with electronic medication administration records (eMARs), which are health IT systems intended to support the administration of medications. These systems often have gaps in communication and information flow that can lead to medication errors, one of the most common safety events. Dr. Ratwani and his multidisciplinary team are establishing a fundamental understanding of the role of eMARs and then building prototypes to address the gaps that are inherent in current systems. As medication errors are responsible for a large number of patient safety events each year, this research could help to significantly reduce medical errors.

A member of the Federal 21st Century Cures Act Health Information Technology Advisory Committee, Dr. Ratwani remains focused on the potential of well-designed and properly implemented health IT systems to transform how care is delivered. Using advanced techniques such as machine learning, he and colleagues continue to work toward a usable and useful system that can support better patient outcomes.

Principal Investigator: Raj Ratwani, Ph.D., Director and Scientific Director of the National Center for Human Factors in Healthcare within MedStar Health, and Associate Professor at the Georgetown University School of Medicine
Institution: MedStar Institute for Innovation
Grantee Since: 2013
Type of Grant: Various

Consistent with its mission, AHRQ provides a broad range of extramural research grants and contracts, research training, conference grants, and intramural research activities. AHRQ is committed to fostering the next generation of health services researchers who can focus on some of the most important challenges facing our Nation's health care system.

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